dna Conversations: Understanding body contouring, and laser hair and pigmentation treatment

To understand more about concepts such as body contouring, and laser hair and pigmentation treatment, dna put together a panel of experts which comprised 
Dr. Malavika Kohli, M.D., D.V.D., D.N.B., Skin Secrets
Dr. Mohan Thomas, Chief Surgeon and Medical Director, Cosmetic Surgery Institute Private Limited
Dr. Geeta Oberoi, MBBS, DPD (UK), AAAM (USA), Managing Director and Founder Member, Skin & You Clinic and
Dr. Sadhana Deshmukh, DNB, DDV, FCPS (Mumbai), Cosmetic Dermatologist and Trichologist, Forever Young Always Skin Hair Body Aesthetics Clinic

During the course of discussions, moderated by Sohini Das Gupta, feature writer and copy editor, the panel unravelled information that was certainly reassuring.

BODY CONTOURING

What is body contouring?
Dr. Mohan Thomas: Body contouring is bringing the body to a fluid flow; going from the upper body to the middle and then the legs. It has to be proportionate; somebody looking very thin on top than at the bottom, catches your eye. So we try to narrow down the difference as much as we can. However, body contouring is never to be confused with weight loss. Question there is, why do people do it? To obviously look their best. There are no health benefits. However, it does motivate people into having a better lifestyle. They start exercising to maintain it. There are surgical and non-surgical ways to body contouring. 
They are basically three technologies—radiofrequency, ultrasound and cryolipolysis.

What is a non-invasive procedure and who should be looking at it?
Dr. Geeta Oberoi: A non-invasive procedure is a non-surgical procedure, with no needles involved. 
We have to divide our patients. So, we work with BMIs—does the patient fall under moderately obese or obese BMI? I would still treat a moderately obese patient if he’s willing to go on a weight-loss or exercise regime with my system. We’ve had ladies with diabetes or who are post-50, who have also worked well with body contouring non-invasive systems. But body contouring does not work with obese people.

Dr. Mohan Thomas: Non-surgical techniques have two parts: part one, deliver the technology and part two, compliance from the patient.

Dr. Geeta Oberoi: The Accent Alma, which is a combination of ultrasound and radiofrequency to melt the fat and tighten skin at the same time, does deliver the desired result. We've seen six to eight inches go down. Of course patients have to maintain a good diet. Patients who are obese, diabetic, who have thyroid or multiple conditions are not good candidates. It’s not a weight-loss treatment, but an an inch-loss, contouring treatment.

Dr. Malavika Kohli: Historically, if you look at body contouring and shaping, it started with liposuction as the golden standard. But with techniques and technology, patients are given a solution that is a combination of methods. A lot of plastic surgeons, after doing liposuction, will use a body contouring device for the stubborn portions or for a small portion. A young lady may not want surgery and yet wants to lose that stubborn, small area of fat. At other times, we start with one system and then realize that surgery is the only option. So there are many ways in which we combine techniques, technology and surgery to deliver the best results to patients. 

What's an acceptable age to go in for body contouring? And what is the estimated cost?  Could you provide some tips to sustain the change that the body contouring procedure has brought about?
Dr. Malavika KohliKohli:  Younger patients between 20-30, who do not have hormonal conditions like polycystic ovary syndrome are ideal. As far as possible, patients who have hormonal conditions should be discouraged from opting for body contouring, because body contouring is not only using a machine; there's a diet to be followed, which is like a distinct lifestyle and not many youngsters follow it. They eat lots of junk food, it’s not that they cannot eat what they want, but it has to be a disciplined, active lifestyle. I would not recommend body contouring for teenagers.

Dr. Sadhana Deshmukh: Body contouring works on particular areas; there are stubborn fat pads like on your stomach, love handles, and on your arms and the Alma radio frequency machine that I contours and tightens these areas. 

What is the approximate cost?
Dr. Sadhana Deshmukh: The cost depends on what machine is being used and the you consumables. As a doctor you can't provide such technology at a cheaper rate to your patients. We select machines, which have no consumables, so that you can standardize the cost. For example, the machine that I have—Accent Alma—has no consumables, no downtime. These machines work on an in-motion technology and need a couple of sessions, because these machines—like these treatments—are non-invasive.

Results will not be visible at the first go. Body contouring requires once-a-week treatment, whereas face contouring in a non-invasive way needs to be done once in three weeks. So, on an average, you need to five to eight sessions to deliver the desired result.
You can have fixed rates for these five to eight sessions, or do an individual costing. Roughly, it can start at Rs. 10,000 with no upper limit. 

Are there any do's and don’ts, post the body-contouring procedure?

Dr. Geeta Oberoi: When using the Accent Alma, the only thing we advice a patient is good amount of hydration—before and after the procedure. It helps us to push the fat out of the body faster. 
Besides hydration, as mentioned before, a balanced diet and exercise is important 

Dr. Mohan Thomas: Patients need to be counselled. 

Dr. Geeta Oberoi: Patients too are responsible for the way they sustain their look post procedure. They cannot blame us or our systems.

LASER HAIR REMOVAL

Laser hair removal is said to be the only existing method of permanently getting rid of your body hair. So, how safe is laser hair removal? What would be good reason to opt for it?
Dr. Malavika Kohli:  It's not permanent hair removal, it's long-term hair reduction, whether it's for the face or body. Certain areas of the face are hormonally dependent, therefore, even if the laser reduction sessions are successfully complete, due to hormone changes, regrowth is not uncommon. Maintenance sessions are then required. As far as the body goes, most areas of the body—underarms, bikini area, legs, arms, forehead, eyebrows—are not hormonally dependent and do extremely well. It’s all about getting rid of a lifetime of hair in 8-12 sessions. It's 95% to 99% freedom from hair.  However, this is not true for the face, although most requests come for removal of facial hair. Hair removal for the body, ears, shoulders, back and chest, and even to shape their beard is not uncommon. 

Is it safe? Absolutely! That's because technology has been around for a long time and is designed to target only the hair follicle. We know where the hair follicle lies and it's depth in the skin (around 3 mm). The laser is a beam of light—one beam of light that has a precise target. Even if you want that laser to treat something else, while it is focusing on another specific hair folicle, it rarely can. Fantastic results can be expected as long as the skin has cooled adequately, the laser beam passes through safely and hits its target.
 
When we say long-term, what length of time are we looking at?

Dr. Malavika Kohli: If someone does the body areas, which are non-hormonally dependent, it can be done in about 8 to 12 sessions. Men may need up to 15 to 20 sessions for their shoulders, chest and back, because testosterone stimulates their hair growth. Laser treatments for long-term hair removal in these areas can last a lifetime. It may come back after 10 or 15 years.

The face, however is a grey zone, and that grey zone can be rather variable, because hair removal procedures for a young girl shouldn't be started till at least three years from the day she got her period, what we say age of menarche. If one suspects having hormonal problems, one needs to wait, establish what's the problem, then start laser hair removal at the right time.
Dr. Malavika Kohli: Those with hormonal problems may need maintenance every three to six months post their initial 8 to12, because hormones fluctuate.

Be it hair removal or body contouring, it's not a women-dominated territory anymore. So what is the demographic like? Do you get a lot of men, are they men from a certain profession? 

Dr. Mohan Thomas: In 2003, when I came back from the U.S., the women were way ahead in terms of this. Today, men are not that far off. Regarding hair reduction, there are enough men coming in and not only from the media. They come in to remove the hair on their body and arms (especially men that are into bodybuilding).

If you look it from a hygiene point of view, hair on the body harbours some amount of bacteria. So there are some health benefits as well. 

There is this notion that natural body hair is supposed to protect you from UV rays and immediate exposure to the harsh natural elements. How does this fit in with hair removal?

Dr. Sadhana Deshmukh: Most women don't want hair on their body, whether it is protecting their skin or not. Normally, having hair on your body its not giving you any great advantage as far as sun protection is concerned. Areas like the underarms and bikini area, where one has thicker hair growth that they wish to get rid of are always covered. 

Dr. Malavika Kohli: There are three components of health; physical, mental and emotional. Procedures like laser hair removal are contributing to your emotional health.
We all shave, wax and thread, if there's a more long-term solution, why not?

Dr. Geeta Oberoi: If you go through a lifetime of waxing at any hi-end salons, you will pay Rs 5,000-6,000, exclusive of taxes. But with laser hair removal, within a span of two years, you're done. 

Dr. Sadhana Deshmukh: There are types of hair—thick, curly, dark hair—which will respond better to the laser hair removal treatment. When people have thick hair growth that needs constant shaving or waxing, it might lead to folliculitisor boils.

Laser hair removal is supposed to painless. Could you elaborate on that?

Dr. Sadhana Deshmukh:  In fact, initially lasers were very painful and that is the main reason why many patients refused laser hair removal. Now with the advancement of technology, we have pain-free machines. There are certain technologies, for example, the Alma machines, that have in-motion technology—your hand is constantly moving, thus reducing the pain factor tremendously and making the treatment safe and comfortable.
Pain is very individualistic, each one's tolerance and sensitivity to pain is different. Pain-free doesn’t mean that the patient won't feel a pinch.
If the patient has softer hair, the pain during the laser hair removal treatment will be negligible or zero. Whereas for men, who have thick, curly, dark, coarse chest, may experience a little discomfort in the first one or two sessions. Eventually the treatment makes the hair softer and finer, like baby hair.

So, if on a scale of one to ten, if the pain factor with waxing is ten, with lasers its almost two (depending on the patient's sensitivity)

Dr. Geeta Oberoi:  Some of the technologies have their own chill tips and a certain amount of cooling added to the systems. So when the procedure is underway, the cooling works as numbing and that also takes the pain factor down.

Dr. Malavika Kohli: Some of the newer systems at Alma also have combined wavelengths—to lower the energies, while keeping the pain factor almost nil. So finally the number of sessions are shorter. 

Dr. Mohan Thomas:  This laser machine in all parts of the world is sold only to a licensed physician. In this country, beauticians, beauty parlors, all have them. People need to understand that this laser machine should be operated with the supervision of a certified dermatologist or plastic surgeon or somebody who is certified in laser physics, because in case of an untoward effect, they can appropriately deal with it, as opposed to a beauty parlor. 

Lastly it's important to get the right machine. Why am I using Alma? Because it is a U.S. FDA approved machine, which gives our patients a certain amount of confidence regarding the safety of the machine. 

Dr. Malavika Kohli: Regarding the price, it is connected to safety. 

Dr. Sadhana Deshmukh: Doctors go through intensive training for more than 10 years before they start treating people. And that's how you can assure that it is safe.

Dr. Malavika Kohli:  Salons don't know how the hair cycle forms or which patients have polycystic ovaries?  How the patient's skin would react to the lasers? They may end of giving the person more hair, if the proper settings aren't used. 

Cost wise, is laser hair removal viable in contrast to a life-long regime of threading and waxing? Is it something that only a certain socio-economic section can afford?

Dr. Sadhana Deshmukh: The small areas—upper lips, chin, underarms, bikini areas, are not expensive at all.  But if someone wants to do a full-body laser hair removal treatment,  as a doctor, I’m spending my entire day for one session. It might fall expensive for some patients then. 
Full body waxing and threading involves a great deal of regular pain and discomfort, but with a couple of sessions of laser hair removal, they are hair-free.

Dr. Malavika Kohli: It’s a one-time cost versus a lifetimes of cost, which you will shell out in small doses for threading or waxing. 
For those who genuinely need it, women who thick dark hair on the face—the sidelocks, on the chin, upper lip, cheeks, chest, her midriff, or the lower back, hair reduction is required through laser treatments. It gives long-term benefits with no side effects. 

Dr. Mohan Thomas:  Under the watchful eyes of a specialist, unwanted pigmentation caused by waxing, or threading is avoided with laser hair reduction treatments. 

What is the right age to opt for laser hair removal. Is there any lower limit? 

Dr. Mohan Thomas:  Menarche, which is the onset of puberty, is a good starting point.
That said, if somebody hits puberty at age 12, you don’t want them to get distracted by hair reductions treatments. They need not give undue attention to hair unless they are ready and mature enough for it.

PIGMENTATION

Indian skin tones come with a huge shade and variety, but we often confuse complexion with pigmentation. How would you explain pigmentation?

Dr. Geeta Oberoi:  Pigmentation is increased pigment or melanin in certain areas. We have different skin colours and skin types. Between a fair-skinned and duskier-skin toned person, the latter might be considered to have more pigmentation in general. But the fair-skinned person could have a pigmentation problem given that the distribution of pigments in her skin could be uneven, causing darker patches. 

Pigmentation is of different types, it can be superficial or deep. Some people are born with inherent pigmentary lines, while some pigmentation can be medically oriented—a person can get it post-pregnancy or post acne or any other damage to the skin. 

Would you say that the treatment for people with different kinds of pigmentation issues are different and how does the treatment work?

Dr. Sadhana Deshmukh:  Pigment means colour. Any color on your body is a pigment, it can be a light pigment or a darker pigment. White spots are called di-pigmentation, because there is no colour. When the colour of the pigment is darker than your skin color—brown or blac—it is called hyperpigmentation. Most patients have hyperpigmentation.
Hyperpigmentation can vary from simple tans caused by the sun, which is a temporary pigmentation, If you use good sun protection and undergo basic treatments and your tan will go.

Then there certain pigmentary demarcation lines on our body, which runs in certain communities. Indians, for example, will typically have dark circles and butterfly pigmentation, which moves from the under-eye area to the cheeks. It is called pattern pigmentation. Pattern pigmentation can only be reduced. It cannot be completely removed. Hormonal pigmentation, which happens after pregnancy, called Melasma, typically appears on the cheeks and nose. Melasma too cannot be 100% treated; it can only be reduced. 
Certain factors—stress levels, products, use of hair dye—will aggravate your existing pigmentation 

Even if pigmentation can be reduced, it helps boost the patient's confident level. 

How would you breakdown the technology behind treating the Hyperpigmentation or Dipigmentation? What's the technology?

Dr. Malavika Kohli: It has been studied that amongst the four metros of India, Chennai gets the highest UV radiation and Calcutta gets the least. Skin of colour—type four, five and six skin type—has certain genetic prototypes which make us more prone to pigmentation. And because we're more prone to pigmentation, all we need is a trigger. A slight trigger in addition to living in a region of the world that has high UV radiation, is enough to cause hyperpigmentation. In fact, studies have shown that now infrared is also a big cause of pigmentation. 

Now, coming to the technologies, they have to be designed knowing all this. Our protocols have to be different from any other region of the world.

Dr. Kohli:  The protocols we follow for treating skin is a combination of techniques and technology—the pre-care, the after-care, the sun-care we need to take, the cooling technique of the machine used in the procedure are all very important. The technology is vital, because it has to be designed to protect the skin, while treating the pigmentation.
The treatment causes a washout of the pigment. But the person requires enough recovery time and you can't overheat the machine as when you overheat Indian skin, three weeks later you get a rebound pigmentation. Hence we use technology, which is preferably fractionated or conventional technology, at a very low energy.

The treatment needs to be spaced out between three weeks with multiple sessions. A person needs to be prepared to do six to eight sessions and has to follow a strict protection regime before and after the procedure. Most patients have a mixed component of top and bottom pigments. Both have to be treated, but it has to be done as a series of treatments. Top pigment is easier to treat, bottom pigment is more difficult.With strict protocols, the best time to treat is during the monsoon; there is less sun, cloud cover, and people step out less. After 5 pm is also a good time for laser treatments for pigmentation.

Dr. Kohli:  So, it helps to do it in the monsoon, but that doesn't mean you can't do it -- most of my patience for pigmentation who come for lasers, I tell them to come after 5 PM, so by the time they are done with their treatment, the sun is setting; people will have the whole night to rest and next morning they put their sun screen and step out, if they have to. They also need to limit their sun exposure for the first week. If they are planning a vacation to a destination that receives a lot of sun, it should happen one week before or after the laser treatment. 

What makes FDA-approved machines credible? 
De. Mohan Thomas:  The U.S. FDA has four phases. So, when the U.S. FDA says that a machine has their approval, they have taken the machine and tried to understand how it works. Then they take a segment of people and test these machines. Once they are safe (they have common denominators, like how many of these people had adverse effects? Could we call this a therapeutic tool?  If it's put out in the market, are people going to get hurt?), they are available in the market. In the U.S., you cannot even market a product